International Journal of Medical and Health Research Original Research Article

International Journal of Medical and Health Research ISSN: 2454-9142 www.medicalsciencejournal.com Volume 4; Issue 1; January 2018; Page No. 133-135

Assessment of the patients suffering from in IGIMS, Patna

Dr. Bijay Kumar1, Dr. Sukumar Jha2 1 Senior Resident, Department of General Surgery, IGIMS, Patna, Bihar, India 2 Professor & HOD, Department of General Surgery, IGIMS, Patna, Bihar, India

Abstract Hydrocele is one of the commonest diseases occurring worldwide. Since olden days surgical procedures have been described for the treatment of hydrocele. The surgical procedures commonly used for the treatment of hydrocele is the radical operation in which the parietal layer of the is completely removed and its cut edges are sutured posteriorly. Hence the present study was planned to assess the clinical profile of the Hydrocele in the patients referred to the IGIMS Patna. The present study was planned on the 25 patients diagnosed with the Hydrocele in General Surgery Dept, IGIMS, Patna from Jun 2008 to Nov 2008. In all the cases, routine investigations were done which included hemogram, random blood sugar, blood for TC, DC, ESR, . The data generated from the present study suggest that the diagnosis and treatment of hydrocele are relatively simple and less complicated the number of patients with hydrocele is high in communities. The social stigma, ignorance, poverty, lack of awareness and lack of health care facilities in areas are the common causes of late presentation. Hence awareness about hydrocele should be spread among the rural populations and they should be encouraged to avail early medical attention.

Keywords: hydrocele, scrotal swelling, testis, clinical feature

Introduction result of groin related surgery or a physical . Sometimes, Hydrocele is a condition wherein watery fluid accumulates inflammation or () in the can around the testicles. This leads to the swelling of the . also be the cause. Older males have a higher propensity. While there is no pain associated with it, the person may Hydrocele may also surface along with cancer in rare experience mild discomfort besides an ungainly body image. cases. There are two types of – communicating Hydroceles are most common in new born male infants but hydroceles have the fluid flow in and out around the testicles can also occur later in life at any age. A hydrocele testis is an while non communicating hydroceles occur when the body accumulation of clear fluid in the tunica vaginalis, the most does not absorb the fluid away from the sac surrounding the internal of membranes containing a testicle. A primary testicles. hydrocele causes a painless enlargement in the scrotum on the A hydrocele feels like a small fluid-filled balloon inside the affected side and is thought to be due to the defective scrotum. It is smooth, and is mainly in front of the testis. absorption of fluid secreted between the two layers of the Hydroceles vary greatly in size and are typically painless and tunica vaginalis (investing membrane). A secondary hydrocele harmless. However, as the fluid continues to accumulate and is secondary to either inflammation or a in the testis. the scrotum further enlarges, more discomfort can be A hydrocele usually occurs on one side, but can also affect expected. Large hydroceles will cause discomfort because of both sides. The accumulation can be a marker of physical their size. Sometimes pain can be in both testicles as pressure trauma, infection, tumor or surgery [1], but the cause from the enlarged area puts pressure against the unaffected is generally unknown. Indirect indicates area which can cause discomfort to the normal testicle. It has increased risk of hydrocele. A hydrocele is normally seen in also been found to decrease a man's sex drive and makes him infant boys, as an enlarged scrotum. In infant girls, it appears less active for fear of enlarging the mass. As the fluid of a as enlarged labia. However, hydroceles are more common in hydrocele is transparent, light shone through the hydrocelic boys than girls. region will be visible from the other side. This phenomenon is Some babies are born with a hydrocele. Hydroceles are very called transillumination. common in babies. When babies develop in the womb Symptoms of a hydrocele can easily be distinguished from (uterus), the testicles (testes) move from the abdomen to the , as a hydrocele is soft and fluid-filled, scrotum. Sometimes the passage which allows this to happen whereas testicular cancer feels hard and rough. During does not close completely. This may then lead to a hydrocele embryogenesis, the testis descends through the , developing. Hydroceles can sometimes be associated with a drawing a diverticulum of peritoneum into the scrotum as it hernia. Premature babies have a higher risk to develop descends. This peritoneal tissue is known as the processus Hydrocele. In older children a hydrocele may have other vaginalis. Normally, the communication between the causes such as injury, torsion of the testis or nephrotic processus vaginalis and the peritoneum is obliterated, and the syndrome. If Hydrocele shows up in adult life, it is typically a tunica vaginalis is the tissue that remains overlying the testis

133 International Journal of Medical and Health Research and the . Congenital hydrocele results when the Inclusion criteria: Patients with Solitary selling in the scrotum processus vaginalis remains patent, allowing fluid from the incorporating the testis; The swelling should be positive for peritoneum to accumulate in the scrotum. Through diagnostic transillumination; It should be possible to get above the ultrasound the accumulation of fluids can be diagnosed swelling at the base of the scrotum. correctly. The fluid accumulation can be drained by Exclusion criteria: Swelling arising from the skin of the aspiration, but this may be only temporary. A more permanent scrotum; Solitary swelling in the scrotum which is separate alternative is a surgical procedure, generally, an outpatient from the testis; Diffuse swelling in the scrotum incorporating ambulatory (same-day) procedure, called a hydrocelectomy. the testis but negative on trans-illumination; Swelling in There are two surgical techniques available for which there was associated impulse on coughing and hydrocelectomy. reducibility. Hydrocelectomy with Excision of the Hydrocele Sac: Incision of the hydrocele sac after complete mobilization of the Results & Discussion hydrocele. Partial resection of the hydrocele sac, leaving a The scrotal swellings are one of the common problems in all margin of 1–2 cm. Care is taken not to injure testicular age group and are commonly encountered in surgery OPD. vessels, epididymis or ductus deferens. The edge of the Swellings of scrotum affect the physical well being of the hydrocele sac is oversewn for hemostasis (von Bergmann's patient and present with varied etiology. Since scrotum is technique) or the edges are sewn together behind the placed outside the lower abdomen they are easily noticed by spermatic cord (Winkelmann's or Jaboulay's technique). the patient himself and are also easily accessible for clinical Hydrocele surgery with excision of the hydrocele sac is useful examination by the treating doctor. Most of the scrotal for large or thick-walled hydroceles and multilocular swellings are cystic and the spectrum of disease consists of hydroceles. hydrocoele (commonest cause), haematocoele, pyocoele, Hydrocele Surgery with Plication of the Hydrocele Sac: The chylocoele, spermatocoele, epididymal and sebaceous hydrocele is opened with a small skin incision without further cysts. preparation. The hydrocele sac is reduced (plicated) by suture The hydrocele recurrence rates vary among studies [6-7] using Hydrocele surgery: Lord's technique. The plication technique different sample sizes, different criteria for recurrence, the is suitable for medium-sized and thin-walled hydroceles. The type of the study (prospective or retrospective), degree of advantage of the plication technique is the minimized thickness of the hydrocele sac, the chosen surgical technique, dissection with a reduced complication rate [2]. different inclusion and exclusion criteria, different If the hydrocele is not surgically removed, it may continue to backgrounds of the health personnel involved and follow up grow. The hydrocele fluid can be aspirated. This procedure periods. As a consequence, it is not easy to make accurate can be done in a urologist's office or clinic and is less invasive comparisons across studies. but, recurrence rates are high [3]. Sclerotherapy, the injection of a solution following aspiration of the hydrocele fluid may Table 1: Age distribution of patients with scrotal swellings [4] increase success rates . In many patients, the procedure of Age (years) No. of cases aspiration and sclerotherapy is repeated as the hydrocele < 10 0 [5] recurs . 10-20 1 Hydrocele is one of the commonest diseases occurring 21-30 4 worldwide. Since olden days surgical procedures have been 31-40 7 described for the treatment of hydrocele. The surgical 41-50 8 procedures commonly used for the treatment of hydrocele is 51-60 3 the radical operation in which the parietal layer of the tunica >60 2 vaginalis is completely removed and its cut edges are sutured Total 25 posteriorly. Hence the present study was planned to assess the clinical profile of the Hydrocele in the patients referred to the Table 2: Presenting features

IGIMS Patna. Presenting features No. of cases Scrotal swelling 18 Methodology Scrotal swelling + pain 5 The present study was planned on the 25 patients diagnosed Pain alone (occasional/on exertion) 2 with the Hydrocele in General Surgery Dept, IGIMS, Patna Total 25 from Jun 2008 to Nov 2008. In all the cases, routine investigations were done which included hemogram, random Table 3: Duration of symptoms blood sugar, blood for TC, DC, ESR, scrotal ultrasound. Duration No. of Cases All the patients were informed consents. The aim and the 0 to 6 months 4 objective of the present study were conveyed to them. 7 to 12 months 3 Following was the inclusion and exclusion criteria for the 1 to 2 years 8 present study. 2 to 5 years 6 >5 years 4 Total 25

134 International Journal of Medical and Health Research

Table 4: Etiology of scrotal swellings following varicocele surgery in children. J Urol. 2004;

Etiology No. of Cases 171(3):1271-3. doi:10.1097/01.ju.0000112928.91319.fe. Primary vaginal hydrocele (PVH) 20 PMID 14767329. /epididymal 2 2. Ku UA. KU J, Kim ME, Lee NK, Park YH. The Sebaceous cyst 2 excisional, plication and internal drainage techniques: a Haematocoele/pyocele /chylocele (negative comparison of the results for idiopathic hydrocele.In: BJU 1 transillumination test) Int. 2001; 871S:82-4 Total 25 3. Fracchia JA, Armenakas NA, Kohan AD. Cost-effective hydrocele ablation. The Journal of . 1998; Ultrasonogram can be used to easily differentiate between 159(3):864-7. doi:10.1016/S0022-5347(01)63755-8. encysted hydrocele and funicular hydrocele if one looks PMID 9474170. closely at the internal inguinal ring. Encysted hydrocele 4. Beiko DT, Kim D, Morales A. Aspiration and manifests as a loculated collection above the testis with a sclerotherapy versus hydrocelectomy for treatment of closed internal inguinal ring. Funicular hydrocele appears as hydroceles. Urology. 2003; 61(4):708-12. doi:10.1016/ an anechoic collection separated from the testis inferiorly but S0090-4295(02)02430-5. PMID 12670550. communicates with peritoneal cavity at the internal inguinal 5. Shan CJL, Ucon AM, Arap S. A Comparative study of ring [8]. Clinically, it should be differentiated from sclerotherapy with phenol and surgical treatment for incarcerated inguinal hernia, inguinal lymphadenopathy, hydrocele. J Urol. 2003; 169(3):1056-9. undescended testis and spermatic cord lipoma, which will help 6. Fasana F. Treatment of tropical hydrocele: a study of 273 in avoiding unnecessary invasive procedures [9]. The diagnosis cases. Medicom. 1982; 4:73-75. in the present case report was made easy as the patient was 7. Thomas G, Richards FO Jr, Eigege A, Dakum NK, clinically stable at the time of presentation, and clinical and Azzuwut MP, et al. A pilot program of mass surgery radiological examination also aided to an early diagnosis and weeks for treatment of hydrocele due to lymphatic intervention. filariasis in Central Nigeria. Am J Trop Med Hyg. 2007; Maximum numbers of patients were seen in the age group of 80:447-451. 30 – 50 years with almost equal number of cases seen in most 8. Rathaus V, Konen O, Shapiro M, Lazar L, Grunebaum M, of the occupations indicating that hydrocele does not have any Werner M. Ultrasound features of spermatic cord predilection for an occupation. Most of the patients presented hydrocele in children. Br J Radiol. 2001; 74(885):818-20. within 6 months of development of hydrocele, with a scrotal 9. DMM KT, Khan DM. J Clin Diagn Res. 2004; 8(2):153- swelling and a few had pain and heaviness, some of them had 4. difficulty in walking and sexual act. Right sided hydroceles 10. Campbell MF. Hydrocele of tunica vaginalis- Study of were more common. The average post-operative stay after was 502 cases. SGO. 1927; 45:192-200. Lord's plication 6 days with no gross difference in the average 11. Dandapat MC, Mohapotro SK, Mohanty SS. The hospital stay whether the hydrocele was unilateral or bilateral incidence of filaria as an aetiological factor for testicular but post- operative pain was more in bilateral hydrocele while hydrocele. Br J Surg. 1986; 73:77-8. wound infection and skin oedema were more common in unilateral hydrocele, possibly due to larger size of unilateral hydrocele. There was no incidence of hematoma or recurrence after Lord's plication. Campbell study and Dandapat MC et al. study, hydrocele occurs more commonly on the right side than on the left side.5,6 It can be concluded that the hydrocele has predilection to affect the right side than the left side. But there is no explanation why this predilection to right side. The average number of days of post-operative stay after the two types of operation, the duration of stay was comparatively less with Lord's plication as compared to Jaboulay's procedure.

Conclusion The data generated from the present study suggest that the diagnosis and treatment of hydrocele are relatively simple and less complicated the number of patients with hydrocele is high in communities. The social stigma, ignorance, poverty, lack of awareness and lack of health care facilities in areas are the common causes of late presentation. Hence awareness about hydrocele should be spread among the rural populations and they should be encouraged to avail early medical attention.

References 1. Esposito C. Incidence and management of hydrocele

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